住院心脏康复课件

CardiacRehabilitation

Phase1Dr.Andishmand.1CardiacRehabilitation

Phase1Definitionof

CardiacRehabilitation “Thesumofactivitiesrequiredtoensurepatientsthebestpossiblephysical,mentalandsocialconditionssothattheymayresumeandmaintainasnormalaplaceaspossibleinthecommunity”.WorldHealthOrganisation.2Definitionof

CardiacRehabilGoalofrehabilitationReturntoindependentlivingsituationNursinghomepatientsgenerallyreturntothatenvironment.3GoalofrehabilitationReturntRehabilitationingeneralComprehensiveMultidisciplinaryLongtermMedicalevaluationPrescribedexerciseRiskfactormodificationCounseling/Education.4RehabilitationingeneralComprCardiacrehaboutcomesImprovedpsychosocialwell-beingMortalityreductionofapproximately25%atthreeyears(similartoB-blockersandACEIRx)Noincreaseinmorbidityormortality.5CardiacrehaboutcomesImprovedCardiacrehaboutcomesImprovedexercisetoleranceforCADandCHFDecreasedsymptomsinCADandCHFMulti-factorialinterventionsimprovelipidsMulti-factorialrehabreducescigarettesmoking(16-26%willquit).6CardiacrehaboutcomesImprovedCardiacRehabilitation

SavesLives!Notreatmentincardiacdiseasehasstrongerscientificevidenceorasignificantlygreaterimpactonsurvival.Thescientificevidencehasbeenreviewedbymanyscientificandexpertbodiesoverthelast30years. Everyreviewhascometothesameconclusionthatcardiacrehabilitationisanessentialtreatment.

CRisonlyformofchronicdiseasemanagementwithanevidencebase.

.7CardiacRehabilitation

SavesComprehensivehelpwithlifestylemodificationinvolvingeducationandpsychologicalinputaswellasexercisetrainingcanreducemortalityby20-25%over3years.Oldridgeetal1988;O’Connoretal1989TheEvidence.8TheEvidence.8CostofCardiacRehabilitationTheaveragecostperpatientin2006-7was£413SingledayinaCCUcosts£1,400Angioplasty(doesnotreducemortality)costs£3,000Bypasssurgerycosts£8,000..9CostofCardiacRehabilitationWhoMakesUpTheCardiacRehabilitationTeamPhysicianPhysicalTherapistThenurseTheoccupationalTherapistPsychologistTheDieticianorNutritionistTheExercisePhysiologist.10WhoMakesUpTheCardiacRehabWhoshouldbeinvolved?PatientPharmacistNurseConsultantGPPhysiotherapy

DieticianExerciseinstructorSmokingcessationadvisorSocialServicesPsychologistDistrictNursesPracticenursesHealthVisitorSecondarycare.11Whoshouldbeinvolved?PatientTargetGroupsCoronaryheartdisease(CHD)Exertionalangina.ACS(unstableanginaorNSTEMIorSTEMI)followingmedical/surgicalmanagement.RevascularisationStableheartfailureandcardiomyopathyThoseathighriskofdevelopingCVD:totalCVDrisk>20%over10yearsordiabetesmellitus..12TargetGroupsCoronaryheartdiContraindicationstotherapeuticrehabilitationUnstableangina,leftmaincoronarydzEndstageCHForsystemicdiseaseUnstablearrhythmiasMalignanthypertensionExpandingaorticaneurysm.13ContraindicationstotherapeutContraindicationstotherapeuticrehabilitationCerebralaneurysmorintracranialbleedRecenteyesurgeryorretinalhemorrhageAcute/unstablemusculoskeletalinjuryAcutesystemicillness(pneumonia,pyelo)Severedementia/behavioraldisturbance.14ContraindicationstotherapeutStructureof

CardiacRehabilitationPhase1: In-patient(1stcontact)Phase2: ImmediatepostdischargePhase3: 2-4weekspostdischargePhase4: Long-term,on-going.15Structureof

CardiacRehabiliPhaseICardiacRehabilitationWhatdowedowiththeseverysickpeople?.16PhaseICardiacRehabilitationPhase1UnderstandingofconditionInformation&educationRiskfactorassessmentPersonalisedhealthplanPsychologicalassessment/supportReferralDrugtherapy.17Phase1UnderstandingofconditOutcomesDiagnosisFunctionalCapacityQOLMorbidityMortalityAMI+++++++++++CABG++++++++++Stableangina++++++++PCI++++++?CHF+++++++CardiacTransplant+++++??Valvereplacement+++++??.18OutcomesDiagnosisFunctionalCaFunctionaldeclineduringhospitalizationFunctionTimeNorehabilitationHospitaladmissionPostRecoveryABRehabilitationThresholdofIndependence.19FunctionaldeclineduringhospEtiologyofdeconditioning.20Etiologyofdeconditioning.20Consequencesofdeconditioning.21Consequencesofdeconditioning

StrengthandFunctionalStatus“Function”“Strength”PoorNormalLowHighHealthyAdultsFrailAdultsNearFrailTHRESHOLDEstablishedPopulationsforEpidemiologicStudiesoftheElderly(EPESE).JGerontology,1994;49(3):M109-15y,1994;49(3):M109-15.22

StrengthandFunctionalStatObjectivesofPhaseICardiacRehabilitation

I.Patient&FamilyEducationII.PreventDeleterious

EffectsOfBedrestIII.ProvideASafe

DischargeToHome.23ObjectivesofPhaseI.23ObjectivesofPhaseI

CardiacRehabilitationI.Patient&FamilyEducationModificationofriskfactorprofiletreatmentofhyperlipidemiasmokingcessationtreatmentofhypertensioncontrolofdiabetesregularexercisedietarychanges.24ObjectivesofPhaseI

CardiacEducation.25Education.25ChallengesforthePtandFamilyFrightening,lifethreateningevent(MI,majorsurgery)Achronicillness,reducedlifeexpectancy,symptomsAlteredidentity-aninvalid,walkingtimebombFearsforfamilyandpartnerbeingleftaloneThreattoemploymentandfinancialstatusMedicationsideeffects(lethargy,impotence)BeingtreateddifferentlybyotherpeopleNeurologicalimpairement(esp.cardiacarrestpats.)Makinglifestylechanges,smoking,diet,activity.26ChallengesforthePtandFamiEducationCHDasadiseaseTreatmentincludingmedicationRecoveryprocessCHDriskfactorsSymptommanagementLivingwithCHD.27EducationCHDasadisease.27ObjectivesofPhaseI

CardiacRehabilitationBehaviormodificationstressmanagementathomestressmanagementatworkcreationofhobbies-timeoutconflictresolutionskills.28ObjectivesofPhaseI

CardiacPsychosocialCareReducefearandanxietyAssistwithadjustmentPromotepositiveattitudeFacilitatebehaviourchangeIdentifyneedforfurthersupport.29PsychosocialCareReducefearaInvolvethechildrenTheydon’thavepathologyyetbuttheyhaveallofthesamestressesTheyalsoshouldknowhowtohelpathomeObjectivesofPhaseI

CardiacRehabilitation.30InvolvethechildrenObjectivesII.PreventDeleterious

EffectsOfBedrestMobilizethepatientsoonPreventmuscleatrophyPreventbloodclotformationPreventpneumoniaPreventlethargyObjectivesofPhaseI

CardiacRehabilitation.31II.PreventDeleterious

III.ProvideASafe

DischargeToHomeProvideenoughphysicalstaminatogohomeandperformADL’sReducefear

ObjectivesofPhaseI

CardiacRehabilitation.32III.ProvideASafe

DischargPhaseIismeanttobepreventativeTohavethepatientoperatewithinsafelimits-nottoolittleexerciseandnottoomuchThepatientmustknowwhatactivitiesaresafeandokayIII.ProvideASafe

DischargeToHome.33PhaseIismeanttobepreventPhaseIisalsodiagnosticHowlargewastheinfarct?Whendosymptomscomeon?PatientsshouldhavehadaLLGXTbeforedischarge.III.ProvideASafe

DischargeToHome.34PhaseIisalsodiagnosticIII.PatientAssessment.35PatientAssessment.35

PatientAssessment

InorderforapatienttoenterPhaseICardiacRehab,theymustbemedicallystable..36

PatientAssessment

InorWhoShouldBeEnrolledIn

PhaseICardiacRehab?StablemyocardialinfarctsCABGpatientsPatientswhohavehadangioplastyPatientswho

havehadcardiactransplantationPatientwithOthercardiacpatientsPatientwithnoncardiacdiseasesandhaveseveralriskfactors

PatientAssessment.37WhoShouldBeEnrolledIn

PhaWhoShouldNotDoPhaseI?PatientswithunstableanginaPatientswithacuteCHFPatient’swithuncontrolledrhythmsPatientswithasystolicBP>200mmHgPatientAssessment.38WhoShouldNotDoPhaseI?PatWhoShouldNotDoPhaseI?PatientswithacutepericarditisPatientswithrecentemboliorclotsPatientswithseverecardiomyopathiesPatientswithuncontrolledDMPatintswithsevereASPatientwiththirddegreeAVBlockPatientAssessment.39WhoShouldNotDoPhaseI?PatEvaluation.40Evaluation.40GoalsOfTheEvaluationClearthepatientforanymusculoskeletalproblems-lossofROM,pectusexcavatum,pectuscarinatum,scoliosis,jointpain&swelling,musclestrength.41GoalsOfTheEvaluationCleartGoalsOfTheEvaluationClearthepatientofanypulmonaryproblems-auscultatethelungsPFTresultsobservebreathingpatternslookforscars&restrictionsinthoracicmovement..42GoalsOfTheEvaluationCleartReturnthepatienthome&preparedtogobacktowork-nohome-boundinvalids.Helpthepatienttoknowtheupperlimitsofphysicalcapabilities.GoalsOfTheEvaluation.43Returnthepatienthome&prepIncreasethepatient’sphysicalworkcapacityHelpthepatienttofeelinchargeofmodifyingcoronaryriskprofileGoalsOfTheEvaluation.44Increasethepatient’sphysicaGivehelpfulinformationbacktothecardiacrehabteam:theMD,nurse,exercisephysiologist,psychologist,&dieticianGoalsOfTheEvaluation.45GivehelpfulinformationbackProcessofEvaluationMedicalChartReviewPatient,FamilyInterviewPatientExaminationPatient’sToleranceForExercise.46ProcessofEvaluationMedicalMedicalChartReviewDeterminethepatient’sdiagnosis-MI,CABG,PTCA?Wasthepatientdefribillated?WhatdoestheEKGreportsay?UseofTPAorStreptokinase?.47MedicalChartReviewDetermineMedicalChartReviewWhatdothecardiacenzymessayabouttheMI?.48MedicalChartReviewWhatdoth

.49.49MedicalChartReviewLookatlipidpanels-HDL,TGs,LDL,VLDL,CholesterolLookatECHOreportwallmotion-hypokinesisejectionfractionwallthickness.50MedicalChartReviewLookatliMedicalChartReviewCatheterizationlabreport-whatpercentageofvesselsblockedReadthePFTreport.51MedicalChartReviewCatheterizPatient’smedications?betablockerscalciumchannelblockersnitratesantiarrhythmicsdiureticsMedicalChartReview.52Patient’smedications?MedicalPatient&FamilyInterviewDoesthepatientunderstandwhathashappenedtothem?.53Patient&FamilyInterviewDoesPatient&FamilyInterviewDidtheyhavechestpressureorpainoranginalequivalents?Didthepatienthaveanypredisposingriskfactors-DM,HTN,PVD,hyperlipidemia,familyhx.?.54Patient&FamilyInterviewDidPatient&FamilyInterviewDidthepatientsmoke?Howlongagodidtheystopsmoking-@theemergencyroom’sdoorsor10yrs.ago!.55Patient&FamilyInterviewDidPatient&FamilyInterviewIsthisthefirstadmission?Isthereasupportivefamilynetwork?Isthepatientwillingtoreturntowork?.56Patient&FamilyInterviewIstPatient&FamilyInterviewWillthepatientneedtobevocationallyretrained?Doesthepatienthavehobbies?.57Patient&FamilyInterviewWillPatient&FamilyInterviewIsthepatientindenialastowhathashappenedtothem?Doesthepatientneedpsychiatrichelp?.58Patient&FamilyInterviewIstThePatientEvaluation

PhysicalExaminationROMeval.-passive&activeGrossmusclestrengthSkin-normalcolor?Pulsecheckpedal,femoral,popliteal,carotid.59ThePatientEvaluation

PhysicaSurgicalsites?Tenderpointsonpalpationofthorax?Breathingpatterns-dotheribsflare,doesthethoraxriseappropriately?ThePatientEvaluation

PhysicalExamination.60Surgicalsites?ThePatientEvAuscultatethelungsBloodpressureonright&leftarmsinsupine,sitting&standing-bilaterallyequal?ObservetheEKGmonitorwhensittingandstandingThePatientEvaluation

PhysicalExamination.61AuscultatethelungsThePatienCanthepatientdothefollowingthingsfirstinsupine,nextinsittingandfinallyinstanding?ThroughatotalarmandlegROMactivelyandpassively-positionalperturbationsSelfCareEvaluation.62CanthepatientdothefollowiSelfCareEvaluationcombhair,brushteeth,shave,performalimitedbedbath,washtheunderarmsandgenitalregions,washtheanklesandfeet,etc.canthepatientdress-pants,shirt,socks.63SelfCareEvaluationcombhair,SelfCareEvaluationCanthepatientdoallofthesethingswhilebeingmonitoredonthetelemetryunitinthecriticalcareunitfor:BP,EKGchanges,HR.Whataboutthepatient’ssubjectivesymptoms?.64SelfCareEvaluationCanthepaNext….MoveOutOfBedWhilemonitoringthepatientforEKGchanges,BP&HR:cometooob&cometostandingcanthepatientsupporttheirownbodyweightwithoutassist?canthepatientwalkinplace?.65Next….MoveOutOfBedWhilemonNext….MoveOutOfBedCanthepatientdoaSPTintoabedsidechairorcommode?Canthepatientwalkinplaceorintheroom?Canthepatientsit15-30minutesatatime?.66Next….MoveOutOfBedCanthepNext….MoveOutOfTheRoomWhilethepatientisbeingmonitoredcontinuouslybyEKGtelemetry,forBP&HR:walk25feet&rest-doitagainprogressovertimeasablewithEKG,BP&HRunremarkable.67Next….MoveOutOfTheRoomWhil

Metabolicequivalentofenergyexpenditureforvaryinglevelsofactivity

.68

MetabolicequivalentofeneDetailesandstagesofmobilizationofthepatientshouldbedocumented..69DetailesandstagesofmobilDetailesofpatienteducationshouldbedocumentedinthepatientmedicalrecords..70DetailesofpatienteducatioGraduationUncomplicatedMI’sgohomein5-10daysGraduatefromPhaseICardiacRehabhavingeither:LowLevelGXTFullGXTlater.71GraduationUncomplicatedMI’sgGraduationIfthepatientdoesn’tgetaLLGXTinthehospitalbeforedischarge,thenusuallytheygototheirphysician’soffice1-2weekslaterforamodifiedBruceprotocol..72GraduationIfthepatientdoesnModifiedBruceExerciseTestProtocole.73ModifiedBruceExerciseTestPDischargePlan

Discharge/follow-upplanthatreflectsprogresstowardgoalsandguideslong-termsecondarypreventionplans.Interactively,communicatethetreatmentandfollow-upplanswiththepatientandappropriatefamilymembers/domesticpartnersincollaborationwiththeprimaryhealthcareprovider.74DischargePlan.74DischargePlanDocumenteddischargeplansummarizinglong-termgoalsandstrategiesforsuccess..75DischargePlan.75With

Thanks.76With.76Evaluation

MedicalHistory:Reviewcurrentandpriorcardiovascularmedicalandsurgicaldiagnosesandprocedures(includingassessmentofleftventricularfunction);comorbidities(includingperipheralarterialdisease,cerebralvasculardisease,pulmonarydisease,kidneydisease,diabetesmellitus,musculoskeletalandneuromusculardisorders,depression,andotherpertinentdiseases);symptomsofcardiovasculardisease;medications(includingdose,frequency,andcompliance);dateofmostrecentinfluenzavaccination;cardiovascularriskprofile;andeducationalbarriersandpreferences.Refertoeachcorecomponentofcareforrelevantassessmentmeasures..77Evaluation

MedicalHistory:.7Evaluation

PhysicalExamination:

Assescardiopulmonarysystems(includingpulserateandregularity,bloodpressure,auscultationofheartandlungs,palpationandinspectionoflowerextremitiesforedemaandpresenceofarterialpulses);post-cardiovascularprocedurewoundsites;orthopedicandneuromuscularstatus;andcognitivefunction.Refertoeachcorecomponentforrespectiveadditionalphysicalmeasures..78Evaluation

PhysicalExaminatiEvaluation

Testing:

Obtainresting12-leadECG;assesspatient’sperceivedhealth-relatedqualityoflifeorhealthstatus.Refertoeachcorecomponentforadditionalspecifiedtests..79Evaluation

Testing:.79Interventions

Documentthepatientassessmentinformationthatreflectsthepatient’scurrentstatusandguidesthedevelopmentandimplementationof(1)apatienttreatmentplanthatprioritizesgoalsandoutlinesinterventionstrategiesforriskreduction,and(2)adischarge/follow-upplanthatreflectsprogresstowardgoalsandguideslong-termsecondarypreventionplans..80Interventions

DocumentthepaInterventions

Interactively,communicatethetreatmentandfollow-upplanswiththepatientandappropriatefamilymembers/domesticpartnersincollaborationwiththeprimaryhealthcareprovider..81Interventions

Interactively,Interventions

Inconcertwiththeprimarycareproviderand/orcardiologist,ensurethatthepatientistakingappropriatedosesofaspirin,clopidogrel,-blockers,lipid-loweringagents,andACEinhibitorsorangiotensinreceptorblockersaspertheACC/AHA,andthatthepatienthashadanannualinfluenzavaccination..82Interventions

InconcertwithExpectedOutcomes

PatientTreatmentPlan:Documentedevidenceofpatientassessmentandpriorityshort-term(ie,weeks-months)goalswithinthecorecomponentsofcarethatguideinterventionstrategies.Discussionandprovisionoftheinitialandfollow-upplanstothepatientincollaborationwiththeprimaryhealthcareprovider..83ExpectedOutcomes

PatientTreaExpectedOutcomes

OutcomeReport:Documentedevidenceofpatientoutcomeswithinthecorecomponentsofcarethatreflectsprogresstowardgoals,includingwhetherthepatientistakingappropriatedosesofaspirin,clopidogrel,-blockers,andACEinhibitorsorangiotensinreceptorblockersaspertheACC/AHA,andwhetherthepatienthashadanannualinfluenzavaccination(andifnot,documentedevidenceforwhynot),andidentifiesspecificareasthatrequirefurtherinterventionandmonitoring..84ExpectedOutcomes

OutcomeRepoNutritionalCounseling.85NutritionalCounseling.85Evaluation

Obtainestimatesoftotaldailycaloricintakeanddietarycontentofsaturatedfat,transfat,cholesterol,sodium,andnutrients..86Evaluation

ObtainestimatesofEvaluation

Assesseatinghabits,includingfruitandvegetable,wholegrain,andfishconsumption;numberofmealsandsnacks;frequencyofdiningout;andalcoholconsumption..87Evaluation

AssesseatinghabitEvaluation

Determinetargetareasfornutritioninterventionasoutlinedinthecorecomponentsofweight,hypertension,diabetes,aswellasheartfailure,kidneydisease,andothercomorbidities.88Evaluation

DeterminetargetarInterventions

Prescribespecificdietarymodifications

aimingtoatleastattainthesaturatedfatandcholesterolcontentlimitsoftheTherapeuticLifestyleChangediet.Individualizedietplanaccordingtospecifictargetareasaswellasheartfailureandothercomorbidities.Recommendationsshouldbesensitiveandrelevanttoculturalpreferences..89Interventions

PrescribespecifInterventions

Educateandcounselpatient(andappropriatefamilymembers/domesticpartners